MELD-Na、CLIF-SOFA、AARC-ACLF对乙型肝炎相关慢加急性肝衰竭短期预后的诊断价值

发布时间：2018-10-07 18:47

【摘要】：目的由乙型肝炎病毒引起的慢加急性肝衰竭(hepatitis B virus related acute-on-chronic liver failure,HBV-ACLF),预后极差,短期病死率极高,患者对治疗效果反应差,住院周期相对较长,该病是目前我国最常见的因肝脏疾病而死亡的原因,且近年发病率有增加趋势[1]。但此病不是肝病的终末期,如果能够及时干预,病情有可能好转[2]。国内外专家进行了大量研究,从单因素分析到多因素分析,相继建立了多种评估肝病预后的模型,但目前并没有评价HBV-ACLF预后的特异性评分或模型。各模型在临床上的运用及受到的评价褒贬不一。本研究选取了已得到频繁应用、在欧美人群数据建立起的两个模型,终末期肝病模型联合血清钠(MELD-Na)及慢性肝衰竭-序贯器官衰竭评估(CLIF-SOFA)评分,以及近年新建立的针对亚洲ACLF人群研究的亚太肝脏研究协会慢加急性肝衰竭研究小组(AARC-ACLF)评分。由于东西方肝病患者肝脏损伤病因不同,ACLF诊断标准、预后判断等均有明显差异[3-4]。我国ACLF的定义与APASL专家共识基本一致,但AARC-ACLF目前尚未在我国临床工作中广泛应用,上述评分系统是否适于我国HBV-ACLF患者需要进一步讨论研究。本研究将进一步探索比较MELD-Na、CLIF-SOFA、AARC-ACLF对预测HBV-ACLF患者短期预后的诊断价值。方法选取72例HBV-ACLF患者,根据从诊断ACLF至诊断后3个月时的预后分为2组,经内科治疗病情稳定或好转为A组(29例),治疗无效行肝移植或死亡者归为B组(43例)。收集患者入院后确诊ACLF时的临床资料,选取患者同期临床指标,比较2组的年龄(Age)、凝血酶原时间(PT)、国际标准化比值(INR)、凝血酶原活动度(PTA)、总胆红素(TBIL)、甲胎蛋白(AFP)、血氨(NH3)、血清肌酐(Cr)、动脉血中的酸碱度(PH)、白蛋白(ALB)、血清钠(Na)、静脉血乳酸(LAC)、胆碱酯酶(CHE)、平均动脉压(MAP)、MELD-Na、CLIF-SOFA、AARC-ACLF分值等,使用受试者工作特征(ROC)曲线下面积(AUC)评价上述评分系统对ACLF短期预后诊断的预测价值。结果B组的PT、TBIL、INR、PTA、MELD-Na、AARC-ACLF、CLIF-SOFA高于A组,Na低于A组,差异有统计学意义(P0.05)。两组的Age、Cr、ALB、CHE、AFP、NH3、PH、LAC、MAP,无明显统计学差异。3种评分系统的AUC均大于0.7,提示诊断价值中等。CLIF-SOFA评分曲线下面积(AUC 0.887)优于MELD-Na评分的曲线下面积(AUC 0.764),差异有统计学意义(Z 2.255,P0.0167),CLIF-SOFA和AARC-ACLF评分的曲线下面积(AUC分别为0.887、0.825)、MELD-Na和AARC-ACLF评分的曲线下面积(AUC分别为0.764、0.825)差异均无统计学意义(Z分别为1.361、1.127,P0.0167),MELD-Na、CLIF-SOFA、AARC-ACLF评分所得最佳临界值分别为23.84、8.50、8.50。结论3种评分系统均能较好地预测乙型肝炎相关慢加急性肝衰竭患者的短期临床预后,AARC-ACLF评分系统的研究基础是亚洲人群,所需相关指标方便获得,计算过程简单,临床应用价值更高。
[Abstract]:Objective (hepatitis B virus related acute-on-chronic liver failure,HBV-ACLF caused by hepatitis B virus has poor prognosis, high short-term mortality, poor response to treatment, and relatively long hospitalization period. The disease is the most common cause of death due to liver disease in China, and the incidence of the disease is increasing in recent years. But this disease is not the end stage of liver disease, if can intervene in time, the condition is likely to improve [2]. Domestic and foreign experts have done a lot of research, from univariate analysis to multivariate analysis, have established a variety of models to assess the prognosis of liver disease, but there is no specific score or model to evaluate the prognosis of HBV-ACLF. The clinical application and evaluation of the models are mixed. In this study, we selected two models, which have been used frequently and have been established in European and American population data, the end-stage liver disease model combined with serum sodium (MELD-Na) and chronic hepatic failure-sequential organ failure (CLIF-SOFA) score. And the newly established Asia Pacific liver Research Association (AHA) slow plus Acute Hepatic failure (AARC-ACLF) score for Asian ACLF population study in recent years. There were significant differences in the diagnosis criteria and prognosis of ACLF due to the difference of the etiology of liver injury between the East and the West patients with liver disease [3-4]. The definition of ACLF in China is basically consistent with that of APASL experts, but AARC-ACLF has not been widely used in clinical work in China at present. Whether the above scoring system is suitable for HBV-ACLF patients in our country needs further discussion and study. This study will further explore the diagnostic value of MELD-Na,CLIF-SOFA,AARC-ACLF in predicting short-term prognosis in patients with HBV-ACLF. Methods Seventy-two patients with HBV-ACLF were divided into two groups according to the prognosis from diagnosis of ACLF to 3 months after diagnosis. After medical treatment, the patients were stable or improved to group A (29 cases), and the patients with ineffective liver transplantation or death were classified into group B (43 cases). To collect the clinical data of the patients with ACLF after admission, and select the clinical indexes of the same period. Comparison of age (Age), prothrombin time (PT), international standardized ratio (INR), prothrombin activity (PTA), total bilirubin (TBIL), alpha-fetoprotein (AFP), blood ammonia (NH3) serum creatinine (Cr), arterial blood pH (PH), (ALB), albumin serum sodium (Na), venous milk The mean arterial pressure (MAP) of (LAC), cholinesterase (CHE),) and the score of CLIF-SOFAA AARC-ACLF, etc. The area (AUC) under the operating characteristic (ROC) curve was used to evaluate the predictive value of the above scoring system in the diagnosis of short-term prognosis of ACLF. Results the PT,TBIL,INR,PTA,MELD-Na,AARC-ACLF,CLIF-SOFA of group B was higher than that of group A (P 0.05). There was no significant difference in Age,Cr,ALB,CHE,AFP,NH3,PH,LAC,MAP, between the two groups. The AUC of all kinds of scoring system was greater than 0.7, suggesting that the area under the curve of CLIF-sofa score (AUC 0.887) was better than the area under curve of MELD-Na score (AUC 0.764), and the difference was statistically significant (Z 2.255 P 0.0167). There was no significant difference in the area under the curve (AUC = 0.887 / 0.825) and the area under the curve (AUC = 0.764 卤0.825) in MELD-Na and AARC-ACLF scores (Z = 1.361 / 1.127, P 0.0167, respectively). The best critical value obtained from MELD-NaOH CLIF-SOFAA AARC-ACLF score was 23.848.50 and 8.50 respectively. Conclusion the AARC-ACLF scoring system for predicting the short-term prognosis of patients with chronic hepatitis B associated with acute liver failure is based on the Asian population. The clinical application value is higher.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R512.62;R575.3

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